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Based on rich research behind the documentary series of the same name, The Weight of the Nationis an eye-opening book for an audience inspired by Michael Pollan and Eric Schlosser and hungry for more Readers know America is getting fatter but might not know that 75% of us may be overweight or obese by 2018, that children are at risk for obesity and diabetes as never before, or that obesity is the number one cause of the rise in our nation's health care costs. They might also believe, like many Americans, that obesity results from a lack of self-control. But people today work harder and take better care of their health than ever before. So how could three-quarters of us somehow suddenly lack willpower when it comes to eating right and exercising? HBO, together with the Institute of Medicine of the National Academies, has gathered the nation's foremost experts to explain how we got here and how we can overcome the forces that drive us to eat too much and move too little. --Is exercise enough to help most people maintain an ideal weight? --Could weighing too much during pregnancy set my child up for a lifetime of poor health? --Do "fat kids" ever grow out of it? --How do lack of sleep and too much stress contribute to weight gain? --Why can I eat the same amount as my friend, but I gain weight and she never does? HBO's four-part documentary series premieres in May 2012 and examines the serious health consequences of obesity, shows viewers how to help themselves and their children live healthier lives, looks at the obesity epidemic from every angle, and explores the growing epidemic of childhood obesity.

JOHN HOFFMAN is Executive Producer of HBO’s The Weight of the Nation. He has won Emmy® awards for the documentary series The Alzheimer’s Project and Addiction, among others.

JUDITH SALERNO, MD, MS is the Leonard D. Schaeffer Executive Officer of the Institute of Medicine (IOM), the health arm of the National Academy of Sciences. She is a nationally recognized leader in health policy.

ALEXANDRA MOSS is Co-Producer of HBO’s The Weight of the Nation.

America’s ever-expanding waistline: We see it, we hear about it, and we worry about it! But can anything be done about it? Who or what is to blame?

We know all the usual suspects: red meat, dairy, white flour, refined sugar, high-fructose corn syrup, a lack of exercise, too much television, and the list goes on, and on, and on….

Simple! Right?...Not so fast. There’s a lot more going on below the surface when it comes to what America is eating for dinner (and breakfast and lunch and in between). And that’s what The Weight of the Nation has finally done: dug a lot deeper to uncover what’s going on in our minds, in our stomachs, in corporate America, on our farms and in society’s overall love of food and our relationship with our couch.

The obesity epidemic in America has been a long time in the making and has been nourished by many different sources. The solution to America’s obesity epidemic will not come from quick-fix diets or a new national obsession with working out. The problem for our nation and for each of us as individuals is far more complex.

The answer will only come from learning more about why we seek and consume food, how we are designed to conserve energy whenever possible, and how the world around us compels us to eat more than we should and move far less. Once you know that, you can use that information to lose weight and keep it off.

The Weight of the Nation provides you with all the tools you need—and gives you the power—to think clearly, to better understand your relationships with food and physical activity, and to change the way you eat and move for the rest of your life.

1

The Bad News: We Have a Big Problem

As much as we all wish there were one thing in the fight against fat we could point to and eliminate, there isn’t. Whether you look at individuals or at our society as a whole, the cause is complex. It’s the sum total of all our little daily decisions that results in us eating a little too much and moving too little—which over time adds up to a lot of pounds. For the nation, our obesity problem has been magnified by the actions of industry, agriculture, and government. These forces shape the environment in which we live, work, and play and, often unintentionally, make it harder for us to make healthy choices. Big decisions made by industry, agriculture, and government have a huge impact on the little decisions we make about what we reach for when we’re hungry and how long we sit at our desks and in our cars.The good news is that, to some extent, there are things within our control that we can change to help ourselves, our families, and our communities pursue healthier lives.Obesity is not inevitable. Itcanbe prevented. And, with hard work and the right information, it can even be reversed.We Know We’re Fat … Don’t We?Our national obsession with stick-thin beauty as portrayed in television shows, movies, and magazines has confused an entire generation about what healthy actually looks like. But, equally concerning are the generations of Americans who now look at the overweight and obese people around them and mistake them for people who are at a normal size and a healthy weight.So, if our perspective is so distorted, how can we tell when our fat is an actual problem and not just a bothersome muffin top?How Fat Is Too Fat?If you’re cutting through the fat to try to figure that question out, what are the most important measurements you need to pay attention to? The simple answer is your waist size and your body mass index. The bigger your waist, the more likely you are to be storing an unhealthy amount of fat in your abdomen. Excess fat that accumulates in your midsection is directly associated with your risk of developing the chronic health conditions linked to obesity, so waist size is a critical measurement to know. A quick and fairly accurate way to measure it is as simple as stretching a piece of string around your stomach. Find the circumference of your bare waist just above your hipbones. Men who measure at over forty inches and (non-pregnant) women who measure over thirty-five inches are at risk.One of the terms that gets used most often in discussions about obesity, weight loss, and weight gain is body mass index, or BMI, which is a ratio of weight and height that represents how much body fat you have. The most important thing you need to know about BMI is that it’s the calculation most often used by your physician. It’s also valuable to scientists and statisticians, because it’s a reliable measure that is easy to figure out. Because BMI is so commonly used, it’s crucial to know what yours is. The standard BMI chart is broken down into the following categories:WHAT IS FAT?Adipose tissue, the scientific name for body fat, is required for human development and survival. We all need fat for energy storage, metabolism, growth, brain function, temperature insulation, organ protection, and structural cushioning. (Imagine sitting without it!) But adipose tissue is not the only place fat cells live. They’re everywhere in your body—in your organs and even in your blood.The number of fat cells each person has varies: a lean person has around 40 billion, an obese adult might have 120 billion. How many you end up with depends on many things, including genetics, but scientists believe there are three times in your life when you can make a lot of them—the third trimester just before you’re born, the first year of life, and during puberty.Once you’ve made fat cells and settled at a number, here’s the bad news: That number can never get lower again. When you lose weight, you’re actually not losing any fat cells. The ones you have are just shrinking. An obese person not only has up to three times more fat cells than someone at a healthy weight who’s never been obese, but their fat cells themselves can be twice as large as the fat cells of a lean person. Lose weight, though, and the cells will contract.When you consume excess calories and the body has no more empty fat cells to fill, the only thing it can do to store them is to make more fat cells. Many of the health problems that result from the production of these additional fat cells are caused by the fact that they are not just under your skin. They are also accumulating inside your abdomen, where they surround your internal organs, and, amazingly and dangerously, within some of those organs, like the liver and the heart. When fat begins to accumulate inside your organs, it dangerously disrupts your metabolism.To be healthy, the body of an average (read: non-marathoner) adult woman should be about 21 to 31 percent fat. The body of a healthy, average (read: non–NFL linebacker) adult male should be roughly between 14 and 24 percent fat.Still, BMI isn’t a perfect measurement of our body fat or of our risk for related health conditions. For example, highly competitive athletes tend to have higher BMIs because of increased muscle mass. For the vast majority of us, though, our BMI reflects our level of body fat and our health risks. While the BMI chart is the same for men and women, BMI calculations for children take into account their growth and development and should be determined by a pediatrician at every visit. If the result concerns you and your doctor, you should discuss both its implications and what you can do to help your child.What may surprise you is that you don’t need to have a BMI in the obese range to start developing the adverse health outcomes related to carrying too much weight. Being even a few pounds overweight can start you down the path to type 2 diabetes—and you can tip over into type 2 diabetes without ever becoming obese.The Growing MajoritySo how does the rest of the population look?According to the CDC’s most recent survey of America’s health, released in January 2012, almost 32 percent of 2- to 19-year-olds and nearly 69 percent of adults in America are overweight or obese.In 2010, the obesity rate for adults rose in sixteen states. And how many states saw a decrease? None. While it’s true the rate of increase has begun to slow, that doesn’t mean we’re out of the woods yet.The obesity epidemic is like a flood. The rush of water may have abated, but our nation is still more than two-thirds underwater. And in some demographic groups and income brackets, the floodwaters are still pouring in. Ever since 2005, there is no longer a linear relationship between poverty and obesity. Being wealthy is not nearly as protective against obesity as it used to be.Being overweight or obese isn’t just uncomfortable—it’s also deadly, as obesity is far too often followed by a wave of chronic disease. But the obesity epidemic is not a natural disaster that we can’t do anything about. Unlike a tsunami, this national crisis is completely preventable.

The Worse News: It's Making Us Sick

Collectively, Americans carry more than four and a half billion extra pounds— that’s an average of fourteen and a half pounds per person. This excess body fat, whether it accumulates under our skin, around our abdomens, or inside our organs, wreaks havoc on our bodies, which are simply not designed to carry all that extra weight. As a result, obesity is a culprit behind the countless chronic diseases affecting us today. According to CDC estimates, obesity is associated with approximately 112,000 deaths each year.

Heart Broken

Did you know that every twenty- fi ve seconds someone in this country has a heart attack? This alarming statistic accounts for heart disease’s rank as the number one cause of death for both men and women. More people die from heart- related problems than from cancer, AIDS, respiratory disease, or even accidents. And if you are obese or overweight, you are more likely to have high blood pressure, high levels of triglycerides and LDL (“bad”) cholesterol, and low levels of HDL

(“good”) cholesterol, all of which are risk factors for heart disease. The bottom line: Being overweight or obese places you at a higher risk of developing heart disease and stroke.

According to Dr. Donald Lloyd- Jones, the chair of preventive medicine at Northwestern University, we shouldn’t be surprised by this. “The heart is a muscle like any other in our body,” he explains. But there’s one important exception: “It never gets to rest.” Your heart— the hardest- working muscle— spends every second of every day vigorously pumping blood to the farthest reaches of your body. The larger you become, the harder your heart has to work to keep blood circulating.

The heart’s smooth muscle walls start to thicken and get bigger. According to Dr. Lloyd- Jones, “pretty quickly the thickened heart starts to weaken and eventually tips over into heart failure.”

Clogged Pipes

Arteries are the smooth, elastic vessels that transport blood throughout the body. When you have high levels of LDL, the “bad” cholesterol, it can stick to inflamed sections of the artery walls and eventually build up into deposits called plaques. Just as gunk in the drain of your sink would prevent water from flowing out of the basin and down the pipe, causing a backup, clogged arteries reduce blood flow, increasing the risk of a heart attack or stroke. If a coronary artery is completely blocked off, it interrupts the blood supply to the heart muscle, causing what we know as a heart attack.

For many of us, there is a genetic component to cholesterol beyond our control that cannot be overlooked. If your cholesterol is too high despite being at a healthy weight and eating a healthy diet, there are other ways to reduce it. The discovery and wide use of statin drugs (like Lipitor and its generics) have been a boon to the heart health of our nation. With changes in diet and drug- induced reductions of further buildup of plaque in the arteries, you can dramatically reduce your risk of heart attack and stroke.

A High-Pressure Situation

As the heart pumps harder with increased body size and the arteries narrow with elevated cholesterol, blood pressure almost inevitably begins to climb. High blood pressure, also known as hypertension, is a major risk factor for heart disease and stroke. Sixty- nine percent of people suffering their first heart attack and 74 percent of stroke victims have high blood pressure. The most common contributors to high blood pressure line up perfectly with the modern American lifestyle: being overweight, not engaging in enough physical activity, and eating a poor diet high in sodium.

7 Steps to a Healthy Heart

Wonder what makes for ideal cardiovascular health and whether you meet the criteria? Give your heart a break and show it some love by trying to check off as many of these American Heart Association factors as possible:

1.Optimal cholesterol (less than 200 mg/dL)

2.Normal blood pressure (120/80 or lower)

3.Not having diabetes

4.Lean body mass index (BMI of less than 25)

5.Not smoking

6.Physical activity

7.Healthy diet

Unfortunately, according to the American Heart Association, only 1 percent of American adults meet these criteria. To find out how many you meet, go to mylifecheck.heart.org.

The United States of Diabetes

High blood sugar, the telltale sign of diabetes, is caused by the body’s failure to move glucose out of the bloodstream and into the cells, where it is used for energy. Carrying too much weight, especially when fat is concentrated in the abdomen, makes you resistant to your own insulin, the hormone that moves glucose from your blood into your cells. In response, the pancreas works hard to produce ever- higher levels of insulin in an attempt to keep blood glucose levels from rising.

Type 2 diabetes ultimately ensues when the body’s cells become resistant to insulin and thus cannot properly remove glucose from the bloodstream. And, in some cases, the insulin- producing cells of the pancreas eventually become exhausted, requiring people with type 2 diabetes to take injections of insulin.

Type 2 diabetes affects nearly 27 million Americans and is inextricably linked with obesity: 80 percent of people with type 2 diabetes are overweight or obese. Currently the seventh-leading cause of death, diabetes, if left untreated or poorly controlled, can contribute to a number of serious health problems, including kidney failure, blindness, and amputations. Unfortunately, the somber stats don’t stop there. People with diabetes are up to four times more likely to have a heart attack or stroke than those without it, and 25 percent more likely to die of cancer. The main risk factor for developing type 2 diabetes is weight gain— even going from a BMI of 26 to 27 or 28 can increase your risk substantially.

Type 2 diabetes doesn’t develop overnight. More than 79 million Americans are living with a condition called insulin resistance— also known as prediabetes. As we gain weight, our cells become more resistant to insulin, which results in an inability to transport glucose out of the bloodstream as well as we should. This leads to a high blood sugar level, which can be detected by your doctor with a standard panel of blood work. People with prediabetes are at incredibly high risk of tipping over into diabetes in the near future. But since prediabetes has no symptoms, most of the millions of people with prediabetes don’t even know they have it, which is one reason it’s crucial to have periodic screenings. There are many things that can be done to reverse prediabetes— or even

reverse type 2 diabetes— but you can take action only if you know you have a problem. It’s believed that more than 90 percent of adults with prediabetes and 25 percent of adults with diabetes don’t know they have the disease, because they haven’t been tested for it. For more on the different steps you can take, see chapter 3.

Fatty Liver

When you gain too much weight for the body to store it under your skin, it begins to deposit in your belly and eventually spreads out into some of your organs, especially your heart and other muscles— and, most importantly, your liver. Fat deposits in the liver are associated with the metabolic abnormalities that drive the development of both high cholesterol and type 2 diabetes. The growing obesity epidemic has been closely followed by another rising epidemic of this new condition, called nonalcoholic fatty liver disease. Nonalcoholic fatty liver disease didn’t even exist until recently. And now it’s estimated that as many as 25 percent of American adults have excess fat in their liver.

In some cases, nonalcoholic fatty liver disease progresses into a form of cirrhosis that occurs almost exclusively in people with severe obesity. Almost all liver transplants in this country are performed as a result of cirrhosis, but it used to be that most of that liver failure could be attributed to the effects of alcoholism or hepatitis B and C. Now, however, the number of liver transplants resulting from cirrhosis caused by nonalcoholic fatty liver disease is quickly rising.

The C Word

Obesity doesn’t just affect your heart, vascular system, pancreas, and liver; it also increases your risk of developing some types of cancer, including cancers of the colon, kidneys, and esophagus. In women, it is also linked to uterine cancer and postmenopausal breast cancer. Twenty percent of cancer deaths in women and 14 percent in men are related to being overweight or obese.

Brain Drain

One recent study suggests that being overweight or obese in middle age might increase your likelihood of developing dementia later in life, perhaps by as much as 70 percent. According to Dr. Nora Volkow, a neuroscientist and the director of the National Institute on Drug Abuse, obesity “negatively affects the functioning of the human brain.”

When researchers have compared the brain activity of obese people with the brain activity of those at a healthy weight, studies have shown decreased activity in the areas of the brain that control cognition.

Other Aches and Pains

More than 66 percent of people with arthritis are overweight or obese. The hypertension with which so many obese people struggle makes them 83 percent more likely to develop kidney disease. Obesity also increases adults’ relative risk of health problems such as gallbladder disease, asthma, sleep apnea, and gout.

We know that obesity is a gateway to serious health conditions, but what are the ramifications of having those conditions earlier in life, when your body’s still developing?

Won’t Somebody Please Think of the Children?

In 1970, less than 5 percent of American children were obese. By 2008, that figure had skyrocketed to more than 17 percent. Add in the kids who are overweight, and the number soars to almost 33 percent. In African American and Hispanic communities it’s even higher: 40 percent.

How’s the health of those kids? Not so great. The CDC reports that 20 percent of all American teens, and 40 percent of obese teens, have unhealthy cholesterol levels. Autopsy studies have found that 38 percent of obese children and 13 percent of all children show signs of nonalcoholic fatty liver disease. Pediatricians are now being encouraged to pay close attention to the warning signs of hypertension.

And when it comes to diabetes, children typically aren’t screened at all. Prior to the rise of obesity in this country, it simply wasn’t necessary. Any diabetes seen in children was usually type 1 diabetes (not related to obesity). Type 2 diabetes historically was seen only in adults, and was called adult- onset diabetes. Now that physicians are seeing it in obese children, they had to stop calling itadult- onset,but the health risks are the same.

What will happen when these children who are starting their lives with a progressive disease end up on dialysis before the age of thirty?

Type 2 diabetes typically cuts the life expectancy of a fifty-year-old by six years. The CDC estimates that a ten- year- old with type 2 diabetes will lose nineteen years of his or her life.

A Life Unexpected

There is much speculation— and worry— that the compounding obesity and diabetes crises will actually shorten our national life expectancy. And if that happens, it will be the first time since the rise of modern civilization it occurs not because of natural disaster, famine, or plague, but as the result of chronic diseases.

Whether or not the average life span decreases, the quality of life for many Americans already has. Obesity can deprive those affected by it not only of health, but also of mobility, self- esteem, opportunities, and, in many cases, success and happiness.

Obesity is a national problem, and one that needs national attention in order to fi x it. Every person in this country, even those who are currently at a healthy weight, is or will be touched by obesity in some way. It’s everyone’s problem, and everyone needs to be part of the solution.